Provider Demographics
NPI:1194763557
Name:LAKESIDE OCCUPATIONAL MEDICAL CENTERS, INC.
Entity type:Organization
Organization Name:LAKESIDE OCCUPATIONAL MEDICAL CENTERS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DRIVER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:727-532-7647
Mailing Address - Street 1:5406 HOOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-5330
Mailing Address - Country:US
Mailing Address - Phone:813-248-8149
Mailing Address - Fax:813-884-7085
Practice Address - Street 1:5406 HOOVER BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5330
Practice Address - Country:US
Practice Address - Phone:813-248-8149
Practice Address - Fax:813-884-7085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QX0100X
261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine